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Supporting Mamas Provider Application
Before including a provider's information as a Local Resource on our website, we ask that each provider submit this application for consideration.
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* Indicates required question
Name
*
Your answer
E-mail Address
*
Your answer
What is your profession?
*
Please check all that apply.
Acupuncturist
Childbirth Educator
Chiropractor
Clinical Social Worker
Doula - Birth
Doula - Postpartum
Lactation Consultation (International Board Certified)
Midwife (Licensed or Practical)
Nurse Practitioner - Midwife
Nurse Practitioner - Primary Care
Nurse Practitioner - Psychiatric
Nurse Practitioner - Women's Health
Physician - Obstetrician/Gynecology
Physician - Pediatrics
Physician - Primary Care
Physician - Psychiatry
Psychologist
Psychotherapist
Therapist
Other:
Required
Practice Name
Name of hospital, clinic, practice group, organization or tell us if you are a solo or private practitioner.
Your answer
Street Address
Include unit number.
Your answer
City, State and Zip
Your answer
Phone Number
*
To be included on our website.
Your answer
Website
Your answer
How long have you been in practice?
*
Your answer
How long have you worked with pregnant families and families with postpartum mood disorders (PPMDs)?
*
Your answer
Do you meet the following criteria?
*
License is in current standing
Licensed to practice in the state of California
Certified to practice in the state of California
Required
Do you take insurance?
*
Yes
No
If yes, which insurance do you accept?
Your answer
Do you take Medicaid?
*
Yes
No
Do you offer services in any other language?
Your answer
Do you specialize in offering support to Black, Indigenous and all Persons of Color?
Yes
No
Other:
Clear selection
Do you identify as a queer, trans, nonbinary, gender non-conforming, genderqueer, bisexual, lesbian and/or gay
Yes
No
Prefer not to answer
Other:
Clear selection
Do you specialize in offering support to queer, trans, nonbinary, gender non-conforming, genderqueer, bisexual, lesbian and/or gay persons?
Yes
No
Other:
Clear selection
Are you currently accepting new patients?
*
Yes
No
Other:
Please confirm that if a client reaches out to you that you will endeavor to respond within 24-48 hours if possible
*
Yes
No
Have you completed two or more of the following?
Check all that apply.
Advanced coursework about PPMDs, including CE courses
Member of a professional organization in the field.
Clinical supervision by a PPMD expert.
Participate in professional group to further understanding of PPMD management.
Hold a leadership role in the community: facilitate/lead a support group, present at conferences, volunteer, and/or consult with non-experts.
What are your current professional and volunteer activities?
Your answer
What is your experience in treating women (and men) with pregnancy and postpartum mood disorders?
*
Your answer
What trainings about pregnancy and postpartum mood disorders have you attended (in-person or on the web)?
Please include the names and dates of these trainings.
Your answer
If you prescribe medications, do you have knowledge of:
Current psychiatric medications that are safe to use during pregnancy and lactation.
Where to access consultation about prescribing medication to pregnant and postpartum women, when needed.
What is your clinical orientation and philosophy?
Your answer
Would you like to be included on the Supporting Mamas Local Resources and Providers page/list?
*
Yes
No
Would you like to receive information on upcoming perinatal mood disorder trainings for birthing professionals?
*
Yes
No
Required
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